Form 720CD Application for Lump-Sum Payment

Locating and Paying Participants

e_Form720CD Application for Lump-Sum Payment

Locating and Paying Participants

OMB: 1212-0055

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Application for

Lump-Sum Payment


PBGC Form 720CD


Pension Benefit Guaranty Corporation.
P.O. Box 151750, Alexandria, Virginia 22315-1750

For assistance, call 1-800-400-7242



Plan Name: FX.PrismCase.CaseTitle.XF


Plan Number: FX.PrismCase.CaseIdNmbr.XF

Participant Name: FX.PrismCust.FullName.XF


Date Printed: 01/12/2021



Date of Plan Termination: FX.PrismCase.DOPT.XF



INSTRUCTIONS: Use this form to request a lump-sum payment if you are a child or dependant pursuant to a Qualified Domestic Relations Order (QDRO). When "proof required" is indicated, please enclose a copy of a birth or baptism certificate, or a U.S. Passport, whichever is appropriate, unless you already sent PBGC a copy of this document. If you have questions about other acceptable documents, call our Customer Contact Center at 1-800-400-7242. Please print clearly with dark ink.



  1. General information about you


Last Name

First Name

Middle Name

Other Last Name(s) Used


Social Security Number

Date of Birth (PROOF REQUIRED)

Gender

male




-



-







/



/






female


Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Province


Daytime Phone

Extension

Evening Phone

(




)




-





x





(




)




-






Name of plan participant:




  1. Signature Sign and date this application. Knowingly and willfully making false, fictitious or fraudulent statements to the Pension Benefit Guaranty Corporation is a crime punishable under Title 18, Section 1001, United States Code.


I declare under penalty of perjury that all of the information I have provided on this form is true and correct.


signature



date






Approved OMB 1212-0055

Expires 12/31/15



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitlePayee Information Form_PBGC Form XXX
AuthorPBGC\IOD
File Modified0000-00-00
File Created2021-01-12

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